Provider Demographics
NPI:1467545855
Name:PROGRESS MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:PROGRESS MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARANOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-757-1919
Mailing Address - Street 1:7601 CANBY AVE
Mailing Address - Street 2:SUITE #7
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-2974
Mailing Address - Country:US
Mailing Address - Phone:818-757-1919
Mailing Address - Fax:818-757-3134
Practice Address - Street 1:7601 CANBY AVE
Practice Address - Street 2:SUITE #7
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-2974
Practice Address - Country:US
Practice Address - Phone:818-757-1919
Practice Address - Fax:818-757-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53350207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078170Medicaid
CAW14128Medicare ID - Type Unspecified
G30010Medicare UPIN